Download Anxiety Disorders 1. Generalised Anxiety Disorder

Anxiety Disorders
1. Generalised Anxiety Disorder
2. Obsessive-Compulsive Disorder
3. Panic Disorder
4. Post-traumatic Stress Disorder
5. Social Phobia
6. Specific Phobias
1. Generalised Anxiety Disorder
Introduction
The primary feature of generalised anxiety disorder is excessive apprehension and
worry about things that have yet to happen. This contrasts the anxiety that defines other
anxiety disorders, which occurs in response to more immediate situations and is
typically accompanied by physical symptoms of autonomic arousal. Here, physiological
signs typically involve muscle tension, fatigue, and irritability. Research suggests that
women are more likely to develop GAD than men. The onset of GAD occurs in early
adulthood, and this disorder is chronic unless treated, with a course characterised by a
waxing and waning of symptoms.
The things about which the person worries range from insignificant matters to major
events, and are not limited to big life decisions. The person’s worry shifts from possible
crisis to crisis, rather than focuses on one discrete event. As a result of the worry,
people may find themselves having trouble sleeping or concentrating, impairing their
functioning.
Symptoms
According to DSM-IV-TR, GAD is characterised by the following symptoms:
• At least 6 months of excessive anxiety and worry about a variety of events and
situations
• There is significant difficulty in controlling the anxiety and worry
• The presence for most days over the previous six months of 3 or more (only 1 for
children) of the following symptoms:
o Feeling wound-up, tense, or restless
o Easily becoming fatigued or worn-out
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•
o Concentration problems
o Irritability
o Significant tension in muscles
o Difficulty with sleep
The symptoms cause clinically significant distress or problems functioning in
daily life
Risk factors and causes
An inherited generalised biological vulnerability may be implicated in GAD, as GAD has
been found to run in families. However, rather than a specific feature that directly
causes GAD, it seems that people inherit the tendency to become anxious. Some
physical conditions may also lead to symptoms that resemble the worry seen in GAD.
They include gastroesophageal reflux disease (GERD), hypothyroidism or
hyperthyroidism, and menopause.
In addition, heightened threat sensitivity also appears to be related to the development
of GAD. People with this disorder are highly sensitive to threat in general, particularly to
a threat that has personal relevance, and allocate attention more readily to sources of
threat than do people who are not as anxious. This increased sensitivity may have
developed in response to early stressful experiences, which taught them that the world
is a dangerous place, things are out of their control, and they lack the ability to cope.
This anxious reaction is entirely automatic or unconscious and contributes to symptoms
of GAD. Current stressors may also cause excessive worry, triggering the onset of
GAD.
Treatment
Pharmacological treatment involves benzodiazepines and antidepressants.
Benzodiazepines provide some relief for patients, at least in the short term, and only
have a relatively modest therapeutic effect. However, they are the easiest and most
common form of treatment for this disorder. Because the side effects of
benzodiazepines are serious, benzodiazepines are best used for the short-term relief of
anxiety associated with a temporary crisis or stressful event. An alternative is the use of
antidepressants (e.g., selective serotonin reuptake inhibitors), which may work better
than benzodiazepines and have less negative side effects.
Psychological strategies mainly consist of cognitive-behavioural techniques. Cognitive
restructuring is used to get patients to evaluate the realistic nature of their worries, and
to recognise that their worrying is excessive. Exposure to the worry process involves
focusing patients’ attention on a horrible potential event, causing them to feel anxious.
Then, patients learn to use cognitive strategies and other coping methods to
appropriately counteract and control the worry process. In the long run, this method of
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therapy should help to reduce anxiety associated with such thoughts. Relaxation
techniques can also be useful in decreasing tension.
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2. Obsessive-Compulsive Disorder
Introduction
Obsessive-compulsive disorder is defined by the presence of either obsessions or
compulsions. Obsessions are essentially intrusive thoughts, impulses, or images that
cause significant anxiety or discomfort in the individual, and are typically perceived as
out of the person’s control. Compulsions are usually ritualistic behaviours (physical or
mental) that are performed in response to obsessions, and are used to neutralise the
distress caused by the obsessions. There are five main categories into which
obsessions can fall. They are contamination, aggressive impulses, sexual content,
somatic concerns, and need for symmetry. The majority of people with OCD have more
than one type of obsession. Examples of compulsions include washing, checking,
arranging items in a certain way, and even mental acts such as counting and repeating
phrases.
OCD appears to be as common in men as in women, but follows a different course
depending on sex. Men tend to begin experiencing symptoms of OCD in adolescence
(between 13 and 15 years old), while the onset in women tends to be around early
adulthood (between 20 and 24 years old). Interestingly, Singapore has one of the
highest prevalence rates of OCD in the world, at 3%, compared to the 1.6% prevalence
rate found in the U.S.
Symptoms
According to DSM-IV-TR, OCD is characterised by the presence of either obsessions or
compulsions:
• Obsessions as defined by (1), (2), (3), and (4):
o (1) Recurrent and persistent thoughts, impulses, or images that are
experienced at some time during the disturbance, as intrusive and
inappropriate and that cause marked anxiety or distress
o (2) The thoughts, impulses, or images are not simply excessive worries
about real-life problems
o (3) The person attempts to ignore or suppress such thoughts, impulses, or
images, or to neutralize them with some other thought or action
o (4) The person recognizes that the obsessional thoughts, impulses, or
images are a product of his or her own mind (not imposed from without as
in thought insertion)
• Compulsions as defined by (1) and (2):
o (1) Repetitive behaviors (e.g., hand washing, ordering, checking) or
mental acts (e.g., praying, counting, repeating words silently) that the
person feels driven to perform in response to an obsession, or according
to rules that must be applied rigidly
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o (2) The behaviors or mental acts are aimed at preventing or reducing
distress or preventing some dreaded event or situation; however, these
behaviors or mental acts either are not connected in a realistic way with
what they are designed to neutralize or prevent or are clearly excessive
In addition,
• At some point during the course of the disorder, the person has recognized that
the obsessions or compulsions are excessive or unreasonable. Note: This does
not apply to children.
• The obsessions or compulsions cause marked distress, are time consuming
(take more than 1 hour a day), or significantly interfere with the person’s normal
routine, occupational (or academic) functioning, or usual social activities or
relationships.
Risk factors and causes
Many factors have been proposed to be related to the development of OCD. OCD
appears to run in families, which means that the likelihood of developing OCD is higher
if a relative has the disorder. The serotonin system also appears to be implicated in
OCD as serotonin reuptake inhibitors are helpful in reducing the intensity of obsessions
and compulsions. Brain imaging research has also found that brain circuits involving
serotonin are activated in people with OCD when their obsessions are triggered.
In addition, those with OCD usually have a catastrophic reaction to intrusive thoughts,
thinking that they hold more meaning or significance than they actually do, which may
explain why they feel the need to neutralise or address those obsessions with
compulsions. However, carrying out their compulsive behaviour reinforces their
maladaptive appraisals because such behaviour prevents them from disproving their
cognitions. For example, if people afraid of germs do not fall sick after washing (the
compulsion) their hands, they might come to the conclusion that they did not get ill
because they washed their hands. However, if they were to simply ignore the thought
and resist hand washing, they would probably find that they would not get sick even if
they did not wash their hands. Furthermore, attempts to reduce threat from an
obsession prevent the natural process of habituation from occurring, maintaining a high
level of anxiety.
Treatment
The primary method used to treat OCD is exposure and ritual prevention (ERP) therapy.
In this form of treatment, the patient is gradually exposed to his or her feared thoughts
or situations in order to trigger anxiety. At the same time, the patient is prevented from
performing any rituals so that the patient can habituate to the aversive stimulus, and
eventually reduce the levels of anxiety or distress associated with these feared stimuli.
Furthermore, cognitively, patients can learn that no harm will result regardless of their
enactment of their rituals. Although much evidence supports the efficacy of ERP
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therapy, many patients are reluctant to engage in this mode of treatment because it
involves facing one’s greatest fears.
Medication can also be used in the treatment of OCD. As mentioned previously, SSRIs
(selective serotonin reuptake inhibitors) have been found to be useful in alleviating OCD
symptoms. However, patients who discontinue their medication have a high rate of
relapse, in contrast to those who undergo cognitive-behavioural treatments, who show a
long-term maintenance of treatment gains. In more extreme cases, psychosurgery is
used when no other treatment seems to work.
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3. Panic Disorder
Introduction
A person with panic disorder experiences recurrent unexpected panic attacks that may
or may not be accompanied by agoraphobia, which is a fear of places or situations from
which escape may be difficult or in which help may not be available to the person in the
case of a panic attack. In most of cases, agoraphobia co-occurs with PD. The use and
abuse of substances are not uncommon in people with PD, as they may function as
safety behaviours or attempts to self-medicate. Another feature of PD is interoceptive
avoidance, the avoidance of internal physical sensations that are similar to those that
occur during a panic attack, such as accelerated heart rate and shortness of breath. For
example, the person may avoid exercise or even climbing a flight of stairs because it
leads to an increase in heart rate. As a result of their anxiety, people with PD become
less and less able to carry out many daily activities or even travel around. In more
severe cases, the individual is unable to leave his or her room. Mood disorders, such as
major depressive disorder, can develop as a result.
Females are twice as likely to have PD than males, and the average age of onset is
between 20 and 24 years old. The prevalence of PD with and without agoraphobia
generally decreases among the elderly. The suicide attempt rate for PD is similar to that
of major depressive disorder at about 20%.
Symptoms
According to DSM-IV-TR, panic disorder is characterised by the following symptoms:
• Recurrent unexpected panic attacks
• At least one of the attacks has been followed by 1 month (or more) of one (or
more) of the following:
o Persistent concern about having additional attacks
o Worry about the implications of the attack or its consequences (e.g., losing
control, having a heart attack, “going crazy”)
o A significant change in behavior related to the attacks
A panic attack is defined as:
• A discrete period of intense fear or discomfort, in which four (or more) of the
following symptoms developed abruptly and reached a peak within 10 minutes:
o Palpitations, pounding heart, or accelerated heart rate
o Sweating
o Trembling or shaking
o Sensations of shortness of breath or smothering
o Feeling of choking
o Chest pain or discomfort
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o Nausea or abdominal distress
o Feeling dizzy, unsteady, lightheaded, or faint
o Derealization (feelings of unreality) or depersonalization (being detached
from oneself)
o Fear of losing control or going crazy
o Fear of dying
o Paresthesias (numbness or tingling sensations)
o Chills or hot flushes
Panic disorder may occur with or without agoraphobia. Panic disorder with agoraphobia
is characterised by:
• Anxiety about being in places or situations from which escape might be difficult
(or embarrassing) or in which help may not be available in the event of having an
unexpected or situationally predisposed panic attack or panic-like symptoms.
Agoraphobic fears typically involve characteristic clusters of situations that
include being outside the home alone; being in a crowd, or standing in a line;
being on a bridge; and traveling in a bus, train, or automobile.
• The situations are avoided or else are endured with marked distress or with
anxiety about having a panic attack or panic-like symptoms, or require the
presence of a companion.
Risk factors and causes
Rather than inheriting a specific vulnerability to develop PD, it seems that people inherit
a vulnerability to stress, which is the tendency to be neurobiologically overreactive to
everyday life events, making them more likely to experience unexpected panic attacks
when confronted with stressful life events. Conditioning also occurs in which cues
present during a panic attack (e.g., palpitations) become associated with certain
situations. Once this happens, these situations may then trigger anxiety in the
individual, ultimately leading to the occurrence of a panic attack.
In addition, patients with PD tend to have catastrophic misinterpretations of bodily
sensations, which could have been learned in childhood. They believe that unexpected
bodily sensations, such as those experienced during a panic attack, are dangerous.
Because of these cognitions, physical sensations resembling those of panic attacks that
could be easily attributable to something else (e.g., exercise) may be interpreted as
dangerous, causing a surge of anxiety. This anxiety, in turn, produces more physical
sensations due to action of the sympathetic nervous system, which the person
perceives as even more dangerous, aggravating his or her anxious symptoms. Thus, a
vicious cycle begins that eventually results in a panic attack. This anxiety over the
development of symptoms is what seems to maintain the disorder.
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Treatment
Medications can be used to treat PD, specifically those that work on the serotonergic,
noradrenergic, and GABA neurotransmitter systems. Drugs that work include
benzodiazepines, SSRIs, and serotonin-norepinephrine reuptake inhibitors (SNRIs).
However, patients show high relapse rates when pharmacological treatment is
discontinued.
Psychological treatments can be exposure-based, in which the patient is exposed to
feared situations or sensations and prevented from using safety behaviours to reduce
anxiety. The aim is to allow the patient to undergo the process of habituation as well as
to learn that there is nothing to fear. Teaching relaxation techniques can also be helpful
in alleviating symptoms. Cognitive therapy is another treatment alternative that involves
identifying and altering patients’ cognitions regarding the dangerousness of their feared
situations. These methods have been found to be highly efficacious, and have more
enduring benefits than medication.
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4. Post-traumatic Stress Disorder
Introduction
Post-traumatic stress disorder involves exposure to trauma of some kind involving
extreme fear, helplessness, or horror. The exposure may be direct or indirect. Thus,
those who experience the event, witness it, work to deal with its aftermath (e.g.,
emergency workers), or are close to a victim of the event may potentially develop
PTSD. Usually, there is a continued re-experiencing of the trauma through various
modalities as well as avoidance of many cues or stimuli related to the traumatic event.
Because intense emotions themselves may serve as a reminder of the trauma, the
person may simply appear numb emotionally to avoid any such experience. The person
is also in a state of heightened arousal and may find it difficult to carry out everyday
activities. The common types of trauma that may induce PTSD include combat, sexual
assault, and accidents.
Associated features of PTSD include depression, impulsive behaviour, guilt (especially
in cases of sexual trauma), and cognitive problems (e.g., difficulty concentrating). The
person may also be plagued by suicidal thoughts as a result of the trauma. Substance
abuse is common in people with PTSD and could be their attempt to self-medicate or
alleviate symptoms.
Symptoms
According to DSM-IV-TR, PTSD is characterised by the following symptoms:
• The person has been exposed to a traumatic event in which both of the following
were present:
o The person experienced, witnessed, or was confronted with an event
or events that involved actual or threatened death or serious injury, or
a threat to the physical integrity of self or others
o The person’s response involved intense fear, helplessness, or horror
• The traumatic event is persistently re-experienced in one (or more) of the
following ways:
o Recurrent and intrusive distressing recollections of the event, including
images, thoughts, and perceptions
o Recurrent distressing dreams of the event
o Acting or feeling as if the traumatic event were recurring
o Intense psychological distress at exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
o Physiological reactivity on exposure to internal or external cues that
symbolize or resemble an aspect of the traumatic event
• Avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or
more) of the following:
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•
•
•
o Efforts to avoid thoughts, feelings, or conversations associated with the
trauma
o Efforts to avoid activities, places, or people that arouse recollections of
the trauma
o Inability to recall an important aspect of the trauma
o Markedly diminished interest or participation in significant activities
o Feeling of detachment or estrangement from others
o Restricted range of affect (e.g., unable to have loving feelings)
o Sense of foreshortened future (e.g., does not expect to have a career,
marriage, children or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma) as
indicated by two (or more) of the following:
o Difficulty falling or staying asleep
o Irritability or outbursts of anger
o Difficulty concentrating
o Hypervigilance
o Exaggerated startle response
Duration of the disturbance (symptoms in criteria 2, 3 and 4) is more than 1
month.
The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Risk factors and causes
A contributing factor to the development of PTSD is a generalised biological
vulnerability that predisposes the individual to be stressed or anxious when faced with a
difficult situation. In addition, certain personality traits may increase the likelihood that
an individual will be exposed to trauma, thereby increasing the risk of PTSD. Childhood
experiences with unpredictable or uncontrollable situations may also teach people that
the world is a dangerous place and that they have little ability to determine their own
circumstances, making them more vulnerable to feelings of anxiety.
Other factors that are more specific to the development of PTSD include the severity of
the trauma (the greater the severity, the more likely PTSD will develop), minimal
education (which has found to be associated with exposure to traumatic events), and
family instability. In particular, if the trauma experienced is extreme, the presence of
biological or psychological vulnerabilities may not matter as much. That is, even if the
person does not seem to have any predispositions to develop PTSD, high levels of
trauma are likely to result in PTSD. Even after exposure to trauma, however, having
strong social support and positive coping strategies that involve active problem solving
can reduce the person’s risk of developing PTSD symptoms.
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Treatment
Typically, treatment for PTSD takes a while, depending on the severity of the patient’s
symptoms. Cognitive-behavioural therapy involves exposure to cues related to the
original trauma, processing the intense emotions that will be triggered, and learning to
develop effective coping procedures. Exposure is usually imaginal and can either be
graduated or massed. In imaginal exposure, the content of the trauma and the emotions
it induces are worked through systematically, with the help of a therapist, until
habituation occurs. The cognitive aspect of treatment might involve correcting negative
assumptions about the incident (e.g., believing that one is to blame for the event and
feeling guilty). In addition, increasing the patient’s positive coping skills and social
support can help to bolster any treatment benefits and ensure that such gains are
maintained. This form of treatment has been found to be highly effective in treating
patients with PTSD.
Pharmacological treatment for PTSD usually involves SSRIs, which help to relieve the
severe anxiety (and even panic attacks) that features prominently in this disorder.
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5, Social Phobia
Introduction
Social phobia is basically a fear of social situations, typically those involving evaluation
by others. The two subtypes of social phobia are generalised and public speaking. The
former refers to a fear of almost all social situations, and is particularly prominent in
children, while the latter specifies a fear with respect to public speaking. In public
speaking social phobia, people have little difficulty with social interaction, but when a
social performance task is required of them, they are overwhelmed by anxiety and the
possibility that they might embarrass themselves. Common physical reactions such as
blushing, sweating, or trembling can induce strong feelings of anxiety in people suffering
from social phobia.
Generally, features associated with this disorder include shyness, sensitivity to criticism,
perfectionism, poor social skills, and low levels of social support. In addition, because
people who suffer from social phobia tend to avoid social situations, there is little
opportunity for them to develop social skills or to build a social network, which does not
help their problem. About 1.5 times more women have social phobia compared to men,
and the onset of this disorder typically occurs in adolescence. This disorder tends to be
more prevalent in people who are between 18 and 29 years of age, undereducated,
single, and of low socioeconomic status.
Symptoms
According to DSM-IV-TR, social phobia is characterised by the following symptoms:
• A marked and persistent fear of one or more social or performance situations in
which the person is exposed to unfamiliar people or to possible scrutiny by
others. The individual fears that he or she will act in a way (or show anxiety
symptoms) that will be humiliating or embarrassing. Note: In children, there must
be evidence of the capacity for age-appropriate social relationships with familiar
people and the anxiety must occur in peer settings, not just in interactions with
adults.
• Exposure to the feared social situation almost invariably provokes anxiety, which
may take the form of a situationally bound or situationally predisposed Panic
Attack. Note: In children, the anxiety may be expressed by crying, tantrums,
freezing, or shrinking from social situations with unfamiliar people.
• The person recognizes that the fear is excessive or unreasonable. Note: In
children, this feature may be absent.
• The feared social or performance situations are avoided or else are endured with
intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or
performance situations(s) interferes significantly with the person’s normal routine,
occupational functioning, or social activities or relationships, or there is marked
distress about having the phobia.
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•
In individuals under age 18 years, the duration is at least 6 months.
Risk factors and causes
Social phobia is likely to involve a generalised biological tendency to develop anxiety, to
be socially inhibited, or both. People with social phobia may also have learned early on
that events, especially stressful events, are out of their control, increasing their
vulnerability to anxiety. They may also be prepared to fear angry, critical, or rejecting
people as a result of early experiences. Furthermore, the person could have learned
growing up that social evaluation is particularly dangerous and might be predisposed to
focus his or her anxiety on events involving social evaluation.
A neurochemical abnormality in the brain involving serotonin may be implicated in this
disorder as serotonin plays a part in the regulation of mood and emotions. The
amygdala may also contribute to the development of social phobia as it is responsible
for controlling fear response. An overactive amygdala may result in a greater fear
response, increasing a person’s anxiety in social situations.
Treatment
Treatment for social phobia involves medications such as tricyclic antidepressants,
monoamine oxidase inhibitors, SSRIs, and D-cycloserine. D-cycloserine enhances
treatment effects when used as an adjunct to psychotherapy. It is an antibiotic that
influences the amygdala and accelerates the rate of habituation, allowing the person to
respond more quickly to exposure therapy. However, as is with most pharmacological
treatments, relapse rates are high when the drugs are discontinued.
One of the most effective treatments for social phobia is group cognitive-behavioural
therapy. Due to the group setting, this mode of treatment is a form of exposure by itself.
As part of therapy, patients practise social interactions and rehearse or role-play their
feared social situations in front of one another to improve social skills and reduce
anxiety associated with social situations. Cognitive restructuring is another treatment
alternative that involves modifying patients’ maladaptive cognitions regarding the
dangerousness of their feared situations. Cognitive therapy addresses patients’
assumed likelihood that a negative consequence will occur as well as severity of such a
negative outcome, and helps them to evaluate the validity of their assumptions. Finally,
cognitive therapy teaches patients how to cope with negative consequences, even if
they did occur, so that the anxiety associated with those situations can be reduced.
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6. Specific Phobias
Introduction
Specific phobias involve an irrational fear of a specific object or situation that
significantly interferes with an individual’s ability to carry out daily activities. Most people
who suffer from a specific phobia tend to have more than one phobia. There are five
broad categories into which phobias can be classified: animal, natural environment
(e.g., heights), blood-injection-injury, situation (e.g., elevators or planes), and other
(e.g., fear of situations that may lead to vomiting).
Generally, females are four times more likely to have a specific phobia than men, and
the median age of onset is 7 years old. Although specific phobias follow a chronic
course, they tend to decline in old age. Interestingly, prevalence rates vary from one
culture to another.
Symptoms
According to DSM-IV-TR, specific phobias are characterised by the following symptoms:
• Marked and persistent fear that is excessive or unreasonable, cued by the
presence or anticipation of a specific object or situation (e.g. flying, heights,
animals, receiving an injection, seeing blood)
• Exposure to the phobic stimulus almost invariably provokes an immediate anxiety
response, which may take the form of a situationally bound or situationally pre
disposed panic attack. Note: in children, the anxiety may be expressed by crying,
tantrums, freezing or clinging.
• The person recognises that the fear is excessive and unreasonable. Note: in
children this feature may be absent.
• The phobic situation is avoided or is endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared situation(s)
interferes significantly with a person’s routine, occupational (or academic)
functioning, or social activities or relationships or there is a marked distress about
having the phobia.
• In individuals under the age of 18 years the duration is at least 6 months.
Risk factors and causes
The initial precipitant of a specific phobia may be a true direct or vicarious experience,
in which real danger or pain causes a fear response. The danger may also be false,
meaning that no real threat was involved. For instance, the person might have
experienced an unexpected panic attack in a specific situation, instilling a fear of that
situation. Under the right conditions, simply being repeatedly told about a potential
danger can lead to the development of a phobia.
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Those with specific phobias may also have inherited a low threshold for responding to
threats with a fear reaction, making them more vulnerable to developing a phobia. The
tendency to be anxious over the possibility of experiencing a feared stimulus in the
future also contributes to this disorder. They may also have learned early on that a
specific object or situation is dangerous and must be avoided at all costs, contributing to
the development of specific phobias.
Treatment
For specific phobias, psychological treatments are highly effective, helping to treat the
disorder 95% of the time. One form of psychotherapy is systematic desensitisation,
which involves creating a hierarchy of feared situations in order of increasing ability to
induce fear in patients. Patients are taught progressive muscle relaxation, which
patients carry out as they imagine or experience one of the items on their hierarchy.
This process continues until the person is able to imagine or experience the scenario
without feeling anxious.
Exposure therapy consists of structured and consistent exposure-based exercises,
typically under therapeutic supervision. In this form of therapy, patients are exposed to
their feared stimulus and exposure is maintained until habituation occurs and their fear
subsides. This method is able to work because it is impossible to maintain a high level
of arousal for an extended period of time. During this time, any avoidance or safety
behaviour is prevented. The exposure can be graduated or massed, and the rate at
which treatment progresses is dependent on the willingness of patients to face their
fears or the intensity of fear that they are able to endure.
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